In a managed care setting, whether it is for commercial or senior products, health insurance is offered individually, through an employer or through Medicare. In all cases, the patient's coverage often changes. Whether it is a change in benefits or moving out of the service area, providers often move in and out of a patient's ecosystem, which then causes disjointed and incomplete health information and assessment of the quality of care rendered. Along those lines, in our current state of healthcare, there is not enough incentive (funding) to measure every health quality measure to ensure optimal healthcare is administered to eligible recipients. There are variations in the collection and reporting of data as well as the categories that are measured between programs. For example, pay for performance programs tend to allow greater flexibility in the ability to capture supplemental data than some of the other programs but are far limited in the number of quality outcomes measured, especially for the high utilizing senior population.
With these varying programs, as well as many health plans introducing their own quality initiatives, it is almost impossible for providers to keep track of the appropriate health maintenance programs for their patient population and much less insure that quality care is being administered. As a consequence, duplication and errors are more commonplace, causing the quality of care to be negatively impacted.
Moreover, managed care is typically restricted to a specific service area and typically incorporates a referral and utilization management process which thus further limits a continuum of care to be administered. It has likewise not been enough to avoid hospital admissions and bend the cost curve. In such scenario, Pareto's Law applies: 20% of the population accounts for 80% of the costs. In order to truly impact the cost curve, care coordination must take front and center, with an immediate focus on the high risk members.
Even though there are many tools in the marketplace, none understand the problem and provide the means to a solution. The perfect tool needs to interface with a range of healthcare data coming from different payors, Electronic Medical Records (EMR) providers, payment systems and so on so as to accomplish two objectives: 1) accurately diagnosing and tracking each specific patient's medical condition and timely updating such information so as to provide a continuously accurate picture of a patient's health; and 2) ensuring that each specific patient eligible to receive healthcare benefits in a given program are administered such that the quality of care adheres to an objective, high-quality standard so that in all cases each patient receives quality care that is commensurate with the accurately diagnosed condition. Unfortunately, no such systems currently exist.